July 26, 2017 Advocacy Alert

Senate Debates Health Care
Dozens of Votes Expected; Advocates Must Continue the Drumbeat

Yesterday, by a narrow 51-50 majority, Senate Republican leadership successfully opened debate on Senate proposals to repeal and replace, or just repeal, the Affordable Care Act (ACA) and to gut Medicaid. The thin margin to move to debate was possible only after Senator John McCain (R-AZ), who is battling brain cancer, flew back to DC to cast a necessary affirmative vote.
The process now is complicated, and will involve dozens of votes over the next several days under a budget process known as reconciliation and a resulting “vote-a-rama,” wherein lawmakers are expected to offer hundreds of messaging amendments for consideration. What this ultimately means for the path forward on health care reform is still unclear. However, we can provide a recap of recent events and prediction about next steps and the possible outcome.
How Did We Get Here?
Because Congress is moving health care reform proposals forward through a process known as “reconciliation,” only a majority of votes in each chamber is necessary to pass a final measure, instead of the usual 60-vote Senate threshold.
Republicans have 52 members in the Senate, and can count on Vice President Mike Pence to break any 50-50 ties. Therefore, Republicans can only afford to lose two votes under reconciliation, which leaves little room for defection. Under reconciliation, however, only bills that have budgetary implications are permissible. The Senate parliamentarian can rule that specific provisions in or entire bills have insufficient budgetary implications and, therefore, require more than a simple majority to move forward. Additionally, under reconciliation, all bills must undergo non-partisan analysis, or be “scored” by the Congressional Budget Office (CBO), in order for the Senate parliamentarian to rule on the budget implications. If bills or amendments have not been “scored,” then they are also subject to the 60-vote threshold. These complicated dynamics are important because they directly affect what has already happened and what happens next.
Yesterday, in a surprise move after the vote to open debate, Majority Leader Mitch McConnell (R-TN) brought to the floor the most recent iteration of the Better Care Reconciliation Act (BCRA), which failed to advance by a vote of 43-57. This version of the BCRA, which was introduced only after the first version, was panned by both moderates and conservative Senate Republicans, included amendments that had not been fully scored by the CBO. Therefore, the bill was subject to the higher vote threshold. Either way, though, it would have failed.
What Happens Next?

Today, the Senate will likely consider a straight repeal of the ACA with no changes to Medicaid. In January, the CBO predicted that if a straight ACA repeal were implemented, it would cause chaos in the health care insurance marketplace and ultimately mean 32 million people would lose insurance coverage by 2026. While Senate leadership is offering the opportunity to vote on this bill as a gesture to the more conservative wing of the caucus that has insisted on the opportunity to vote on a straight repeal, moderates have balked at the cost and coverage implications of straight repeal, and this version is also likely to fail on the Senate floor.
From there, next steps are murky. We expect that throughout the next two days, Senators will vote on a slate of amendments during the vote-a-rama—many of which will be offered by Democrats as messaging amendments (in other words, without any expectation the amendment would pass). Once the vote-a-rama is over, the Senate will then likely vote on all or part of a version of the initial BCRA.
While the CBO has fully scored the first BCRA introduced last month in the Senate—and estimate that 22 million people would lose insurance over 10 years, including 15 million on Medicaid—the Senate parliamentarian recently ruled that major sections of that bill do not pass muster to be considered under reconciliation, and would also be subject to a higher vote threshold to be considered.
Therefore, what we think the Senate will likely ultimately consider is a stripped-down, or “skinny,” version of ACA repeal. This measure would likely include proposals to repeal the individual mandate and roll back a suite of ACA taxes. We do not expect that a “skinny” bill would include the devastating changes to Medicaid, but the Republicans’ policymaking is in flux at this point, so our prediction is far from certain.
How Bad Could a “Skinny” Bill Really Be?

Unfortunately, industry experts have predicted that even a scaled-down bill will throw the insurance markets into chaos and result in coverage loss for 15 million people by next year. While n4a has not weighed in substantively on ACA marketplace policy—instead focusing advocacy efforts on proposed Medicaid cuts—it is likely that major disruption in the marketplace would most acutely harm older, sicker beneficiaries.
It’s critical to understand that the “skinny” bill is not necessarily better than the BCRA in the long run, but merely a way to meet a campaign goal and keep the process alive, allowing Republicans more time to drive an even less-transparent policymaking process in the final stretch.
Here’s how: should a “skinny” repeal succeed in the Senate, it allows House and Senate lawmakers to proceed to a conference process during which they would hash out differences in their bills, or adopt new proposals altogether. The conference process is done behind closed doors and with no input beyond the individual lawmakers that each chamber’s leadership has appointed to the Conference Committee. Whatever comes out of conference would be subject to a straight up-or-down vote on both chambers’ floors without any amendment or changes. This is a terrifying prospect for advocates! 
Advocacy Still Needed!
Make no mistake—even passing a stripped-down bill in the Senate is a dangerous option because it would continue to advance a deeply flawed process that has consistently threated health care coverage for older adults in both the marketplace and on Medicaid. n4a remains opposed to both the process and the proposals that Congress is considering, and it is essential that local advocates continue to weigh in to encourage your Senators to vote against any bill that continues to advance these such provisions.
Instead, we encourage lawmakers to stop this process and begin again in a bipartisan, transparent, inclusive way that seriously considerers the challenges inherent in the ACA and also leaves unrelated Medicaid cuts off the table. Local advocacy is key to stopping these devastating proposals from moving forward. Senators—especially from key states AK, ME, NV, OH, WV, AZ, CO, KS, LA, and MT—must KEEP hearing about how harmful these measures could be to their older constituents. Aging advocates must weigh in now to tell your Senators to reject ANY proposal that keeps the momentum moving toward ACA repeal, repeal and replace and Medicaid cuts.
Please make a quick call, send an email or fax, and encourage your agency’s stakeholders to do the same to keep up the drumbeat about the health care reform proposals that are being considered. You can find contact information for your Senators’ state and Washington, DC offices at www.senate.gov.
The message now to Senators is simple:

I urge you to stop any attempt to either repeal ACA without a replacement or to gut funding for Medicaid. Please reject any proposal during this debate that keeps this process moving toward a secretive conference committee.
Instead, any changes to health care must be done through an open, bipartisan and transparent process that protects older adults and preserves critical Medicaid funding. 

We urge you to continue using n4a #SaveMedicaid (www.n4a.org/savemedicaid) campaign page, for advocacy tools and resources to engage your grassroots and local partners! We also encourage you to share n4a’s Policy Brief, “What Would ACA Repeal Mean for Older Adults, Caregivers and the Aging Network?” This Policy Brief includes key questions and considerations that lawmakers must address in any future attempts to improve the ACA.
Again, advocacy this week is critical. The Senate will be voting today, tomorrow, Friday and possibly over the weekend. The time is short to STOP devastating cuts to health care and long-term care services for older adults.

If you have questions or concerns about this Advocacy Alert or n4a’s policy positions, please contact Autumn Campbell at acampbell@n4a.org and Amy Gotwals at agotwals@n4a.org.